- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $114.82 / $281.84
| Professional | | $93.33 | $114.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $354.81
| Professional | | $100.00 | $154.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $162.18 / $208.93
| Professional | | $147.91 | $162.18 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $141.25 / $436.52
| Professional | | $87.10 | $141.25 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $123.03 / $281.84
| Professional | | $85.11 | $123.03 | $281.84 |